Objectives:
To investigate and clarify which psycho-emotional factors are related to
success in smoking cessation. Results:
Of the 65 individuals who participated in the study, 36 were successful in
smoking cessation. There was an association between the level of addiction to
nicotine and an unsuccessful outcome in smoking cessation (p = 0.009). It was
also observed that failure in smoking cessation was associated with both the
presence of depressive episodes (p = 0.037) but also of severe psycho-emotional
disorders (p <.001). In the binary logistic regression analysis for the
psycho-emotional disorders and relapse chances in Group Success there was no
statistical significance (p> 0.05) in all the variables studied. Conclusion: Among the factors related
to failure in smoking cessation, the presence of severe psycho-emotional and
current untreated alcoholism should be highlighted. The factors related to
successful cessation were the absence of alcoholism and lower levels of
dependence on nicotine.

IntroductionIt is known that smoking
is a worldwide public health problem and the leading cause of preventable death
in the world as a result of tobacco-related diseases.1 Therefore,
various measures to combat smoking are being carried out in order to promote
the prevention and treatment of this disease, defined by the World Health
Organization as "a mental and behavioral disorder due to nicotine
dependency syndrome", which is included in the International
Classification of Diseases (ICD) in the section for mental and behavioral
disorders due to psychoactive substance use (ICD- F.17).2

In Brazil, anti-smoking
actions are intense, with regulatory policies, 3,4 socio-educational
campaigns5,6 and smoking cessation programs.7,8 Among
these interventions, the latter have been developed in most health care
centers, however, there is still no consensus on the success rate in smoking
cessation due to the methodological diversity adopted by cessation programs. Freire
et al.,9 presented a model of a smoking cessation program which
demonstrated high success rates when compared to those found in the literature,
7,8,10-13 with the implementation of new procedures such as: intensification of the frequency of meetings (from once to twice a
week), including a specific date of termination of tobacco and participation of
former smokers in the treatment.

It is worth noting that
one of the factors that interferes with successful smoking cessation is
nicotine abstinence syndrome, which is characterized by the manifestation of a
set of symptoms such as: bradycardia, gastrointestinal discomfort, increased
appetite, weight gain, anxiety, dysphoria, depression, insomnia, irritability,
nervousness, fatigue and difficulty concentrating.14,15 On the one
hand, such symptoms frequently lead to smoking and on the other hand, the great
difficulty in dealing with these symptoms increases the likelihood of relapse,
particularly during the critical period of abstinence (less than six months of
cessation) since the intensity and frequency of symptoms varies from individual
to individual.16 In addition, other factors that can also influence
non-adherence to anti-smoking treatment and smoking cessation are high levels
of anxiety and depression, living with other smokers, a high degree of nicotine
dependence and low motivation to participate in anti-smoking therapies.17,18

There is a clear
association between smoking and psycho-emotional disorders such as depression,
anxiety, attention deficit, panic syndrome and psychiatric disorders,18
however; it is not yet well established in the literature which
psycho-emotional characteristics are determinant in success in smoking
cessation and continued abstinence. The psycho-emotional disorders are related
to mood swings, behavioral changes and emotional instability, however, during
tobacco abstinence these factors are intensified, such as depression, the
individual present no interest in the outside world, there is the feeling of
intense sadness and long-lasting, which undermines the social, emotional and
especially professional life and these negative influences make it difficult to
achieve success in smoking cessation. 19

According to the study
Zvolensky et al. (2015),20 former smokers with a history of
depression, are likely to have relapse to smoking even after 10 years of
abstinence compared to former smokers with no history of the disorder.
Moreover, the chances of relapse to smoking further increase over time in cases
withdrawal of current depression and / or applicant and such relapse is
associated with symptoms such intensity.21 Given the above, this
study aimed to investigate and clarify which psycho-emotional factors are
related to success in smoking cessation.

Methods

Study design and sample selection

This was a prospective,
descriptive study conducted at the Faculty of Science and Technology - FCT /
UNESP of Presidente Prudente/SP, to understand how some participants in a
smoking cessation program even with some personal characteristics that
initially suggest the failure in the smoking cessation process managed to get
the success, ie, they managed to remain for at least six months without
smoking. The study was approved by the Research Ethics Committee of this
institution under protocol no. 245/2008.

The study sample
consisted of 65 participants of both sexes, female predominance (68%) divided
into two groups: Relapse group (n = 29), characterized by those who did not
stop smoking and the Success group (n = 36) characterized by successful smoking
cessation for at least six months.

We included in the study
individuals of both sexes, aged between 35 and 65, that participated of at least three meetings before the date of
smoking cessation proposed by the health care team and who remained abstinent
for at least six months. We excluded individuals who abandoned the program. PROCAT
uses an intensive approach with cognitive behavioral therapy (CBT) associated
with drug therapies and nicotine replacement. The therapy is performed in
groups through structured sessions which take place twice a week, each session
lasting 60 minutes. The first five sessions consist of socio-educational
classes, after which begins the so-called "Stopping Day"
(pre-established date for cessation) that occurs after the presentation and
discussion of all educational classes on the themes proposed by National Cancer
Institute - INCA. Individual reports in group meetings begin from the sixth therapy
session.9

For monitoring the
withdrawal situation of each individual, an abstinence control sheet was
completed which included the presence or absence of relapses, at all meetings
after the proposed date of cessation.

During
the PROCAT admission phase, all participants underwent an initial evaluation,
at which information was collected on personal data, anthropometric
measurements (weight and height) and smoking history (number of cigarettes
smoked per day; duration of smoking in years), education level and
socioeconomic classification according to the Brazilian Association of Research
Companies – ABEP- 2012.22 The motivational stage for change in
behavior according to the Prochaska and DiClemente stages23 was also
evaluated, adapted for the Brazilian population.24 In addition, the
degree of dependence on nicotine was evaluated through the Fagerström Test,
which consists of a scale of six items and scoring from 0 to 10. The classification
of nicotine dependence encompasses five levels: very low (0-2 points); low (3-4
points); moderate (5 points); high (6-7 points); and very high (8-10 points).25
Individuals who present a score of over 6 points are more likely to have
greater difficulty in stopping smoking due to abstinence syndrome.26 Subsequently,
a psychological assessment was performed in order to verify the psych-emotional
state of the participants who would be subjected to the withdrawal process and
investigate possible psycho-emotional disorders that could influence this
process. It should be emphasized that the identification of psycho-emotional
disorders was conducted through self reporting by the participants, and some
presented the prescription drugs that they frequently used. This evaluation
followed the schematic plan presented below (Figure 1).

Figure 1

A psycho-emotional disorder was
considered as something which provoked significant changes in the psychological
and emotional area of the individual, reflected in individual behavior in
social life, in the context of work or family. After the psychological
evaluation, the following psycho-emotional disorders were identified:
alcoholism, anxiety, depressive episodes, severe disorders (characterized by:
panic disorder, bipolar disorder and deep/recurrent depression), critical
moment of life (characterized by situations of emotional instability for the
following reasons: loss of loved-ones, financial problems, marital crisis/separation
and family conflict). In severe disorders and critical life categorie when the
individuals were classified if they had at least one of the subclasses. If the
individual present more than one category of psycho-emotional disorders, it was
considered for classification only the category of most serious disorder.

Statistical Analysis

Data
were analyzed using the statistical software Statistical Package for Social
Sciences (SPSS), version 18.0. Data normality was assumed or rejected by the
Shapiro-Wilk test. Numerical variables were expressed as mean and standard
deviation, and categorical variables were described in absolute and percentage
values. For comparison between groups the independent t test was used for
parametric data and the Mann-Whitney test for nonparametric data. The
chi-square test was used to analyze categorical data. Was used Spearman
correlation test to check the relationship between variables. In addition we
performed a regression test Binary Logistic to check the chances of relapse
according to the classification of psycho-emotional disorders. Adopted the
statistical significance level of p <0.05.

Results

The sample was predominantly female in both groups (83% in the Relapse
group and 56% in Success group) and presented homogeneity as there were no
statistical differences in relation to demographic or smoking-related data.
(Table 1).

Table 1.Profile of the studied sample. Data expressed
as mean and standard deviation.

In this study it was observed that the majority of individuals from both groups
were in the contemplation stage, i.e., they were aware that smoking was a
problem and seriously planned to change their behavior (Table 2). In addition,
Table 2 presents the association between the nicotine addiction level and
failure in smoking cessation (p = 0.009), as the majority of members of the
group of smokers who failed to quit smoking presented higher nicotine dependence
(very high level) when compared with the group that stopped smoking. It was
further noted that there was a marginal difference (p = 0.054) between the
groups in relation to socioeconomic classification. Additionally, there was a
negative correlation between success in smoking cessation and socio-economic
level (r = -0.374; p = 0.002), which suggested that the higher the
socioeconomic status of the individual the smaller the chance of succeeding in
smoking cessation.

Table 2. Descriptive
analysis of the sample with respect to the Prochaska and DiClemente stage,
Fagerström, Educational level and Socio-Economic Class

Table
3 demonstrates that failure in smoking cessation was associated with both the
presence of depressive episodes (p = 0.037) and the presence of severe
psycho-emotional disorders such as: Panic Disorder, Bipolar Disorder and
Deep/Recurrent Depression (p <.001). In addition, it was noted that although
not statistically significant, there was a marginal difference between the
groups in relation to treatment for alcoholism, which allowed us to assume that
alcoholism, when treated, greatly increases the chances of success in smoking
cessation. Figure 2 is a graphical representation of the prevalence of
psycho-emotional disorders according to the relapse and success groups. Among
the individuals who demonstrated some kind of psycho-emotional disorder, 13
were attending psychological and/or psychiatric counseling, representing 28% in
the relapse group and 14% in the success group.

Table 3. Association between the psycho-emotional
characteristics and success in smoking cessation according to the group:
Relapse Group (RG) and Success Group (SG).

Logistic
regression analysis (Table 4) shows that the psycho-emotional disorders except
treated alcoholism, adversely impacted the chances of success Group to remain abstinent,
because untreated alcoholism, depressive episodes and serious disorders have
100% relapse chance. Already treated alcoholism, anxiety and critical life time
have 29%, 41% and 50% chance of relapse respectively. However, for all
variables there was no statistical significance (p> 0.05).

Discussion

In the present study it
was found that the psycho-emotional characteristics with higher prevalence in
the relapse group were serious disorders (Panic Disorder, Bipolar Disorder and
Deep/Recurrent Depression) with 37.9% and anxiety with 20.7%. What is
interesting is that these serious disorders, even when being monitored, are
directly associated with failure in smoking cessation, however, this could be
justified by the exacerbation of psycho-emotional symptoms during the period of
abstinence, which greatly increases the risk of relapses during treatment.27
In addition, high levels of nicotine dependence are significantly
associated with level of depression and low rates of success11,28
this corroborates the findings of the present study, which also found an
association between high levels of nicotine dependence and failure in smoking
cessation.

Considering that the
sample was predominantly female, this prevalence may be related to gender. According
to Silva et al. (2012),29 female smokers; present more intense and
frequent depressive disorders than male smokers; have more difficulty enduring
and controlling the symptoms of withdrawal syndrome according to the phase of
the menstrual cycle; and receive less cessation support than men, which makes
them more susceptible to relapses. Male smokers more commonly present the
symptom of anxiety than depression.30

Although anxiety did not
present statistical significance in the present study, it can be considered one
of the complicating factors in the cessation process, since the relationship
between smoking and anxiety is a kind of vicious circle, on the one hand there
are patients who smoke to alleviate the feeling of anxiety and on the other hand,
there are those that compulsively smoke because they are very anxious.17,31
It is important to point out that the difference between healthy and
pathological anxiety is very subtle. However, anxiety becomes pathological when
there are feelings of fear without genuine threat or in cases of a sensation
which is disproportionate to the situation that originated it;32 in
more advanced cases this can eventually become Panic Syndrome.

Another factor related
to failure in smoking cessation is the simultaneous consumption of alcohol or
untreated alcoholism, which in this study was characteristic of the Relapse
group but without statistical significance. Individuals who consume alcoholic
drinks start smoking tobacco earlier and smoke a higher number of cigarettes
over a longer period compared to subjects who do not consume alcohol.33,34
Kahler et al. (2009),35 conducted a study with 4832
individuals and found that those who drank more than once a week, four or more units
of alcohol (considered heavy consumption), had lower smoking cessation rates
compared to the other participants.

In the present study,
the psycho-emotional characteristics which facilitated cessation success were:
the absence of simultaneous consumption of alcohol (untreated alcoholism)
and/or treated alcoholism, the absence of severe psycho-emotional disorders and
lower levels of nicotine dependence. It should be pointed out that the Success
group presented higher incidences of the characteristic denominated
"Critical moment of life" characterized by conflicting situations
such as: Mourning, Financial problems, Marital crisis/separation and Family
conflicts. These situations are in fact challenging, but even so, our study
showed that despite these life setbacks, it was possible to succeed in the
withdrawal process; the most important element in these cases was not to lose
focus on the treatment. Although there is no data in the literature relating to
this variable, it is believed that the higher frequency of meetings in the
early stages of the Intervention Program (PROCAT) may have contributed to
successful termination. In addition, another important factor was the presence
of mild to moderate depressive episodes, reported by the participants
themselves. The literature reports other factors associated with successful
cessation, such as younger individuals being more likely to give up smoking
than older individuals; participants in physical or religious activity (which
provide positive reinforcements to abandon the cigarette) and non consumers of
alcoholic beverages.36 According to Jesen (2012)37, successful
predictive factors of short-term cessation are lower daily cigarette
consumption, participation in CBT sessions and the use of medication to control
the symptoms of withdrawal. In the long term, the predictors of success are the
absence of depressive symptoms and early cessation.

Since psycho-emotional disorders
are determining factors in the success of smoking cessation, it is of paramount
importance that smoking cessation centers and tobacco control and support
programs evaluate and identify these factors so that the psycho-emotional
characteristics of clients can be tracked, thus offering more effective
treatment, with specific approach strategies which contribute to the reduction
in relapse rates and increased success rates during cessation.

ConclusionFrom
the results presented, it was concluded that the presence of severe
psycho-emotional disorders (panic disorder, bipolar disorder and deep/recurrent
depression) and simultaneous untreated alcoholism, were related to failure in
smoking cessation. The factors related to successful cessation were the absence
of alcoholism and lower levels of nicotine dependence. However, the smoking
cessation process is complex, delicate and requires health centers, a
specialized multidisciplinary team that takes into account the psycho-emotional
characteristics of individuals during treatment of smoking in order to choose
the best action strategy that provides the success in cessation and maintenance
of long-term abstinence.

Abbreviations

ICD: International Classification of Diseases;
FCT: Faculty of Science and Technology; PROCAT- Program of Anti-Smoking
Awareness and Guidance; CBT: cognitive behavioral therapy; ABEP:Brazilian Association of Research Companies;
INCA: National Cancer Institute.

Human
Subjects Approval Statement

The study was approved by the Research Ethics
Committee of this institution under protocol nº. 245/2008.

Authors' contributions

DR and EMCR conceptualized the study. RMD,
APCFF and ALPB collected the data. RMD analysed the data and wrote the first
draft. All authors contributed to the final manuscript and approved its
contents.

Conflict of Interest Disclosure Statement

All authors of this article
declare they have no conflicts of interest.

Acknowledgments

The authors are thankful the FAPESP (Sao Paulo
State Research Foundation) by support (Proc. nº: 2013/04091-0 and 2013/03147-2).